Using data from a large national English patient survey we found substantially more negative experiences reported by ethnic minorities (particularly South Asians and Chinese), younger patients and those with poor self-rated health. Differences by gender and socioeconomic deprivation were limited and inconsistent. A substantial proportion of ethnic differences reflected concentration of ethnic minority patients in low-performing practices (consistent with the ‘minorities concentrated in poor practices’ hypothesis, ), but concentration in low-scoring practices explained little of the large differences observed among patients of different age and self-rated health. In spite of large within-practice differences among patients of different ethnicity and self-rated health, primary care practices varied substantially in respect of these differences and in some practices South Asian and Chinese patients evaluated their experience similarly or more positively compared with White patients. This finding suggests that differences in care (‘worse care’ hypothesis, ) may at least in part be responsible for the observed ethnic differences.20
The largest ethnic differences in patient experience were comparable in magnitude to the differences observed between patients in ‘poor’ and ‘excellent’ self-rated health. Although South Asian and Chinese patients reported substantially more negative experiences than White patients, Black/White differences were small and inconsistent in direction. These findings are similar to previous UK findings,5 6 8
and could point to linguistic proficiency as one determinant of ethnic differences (consistent with the ‘receive same care but report worse experience’ hypothesis, ).7
Most UK Black patients are descendents of immigrants from English-speaking countries, which contrasts sharply with the distinct linguistic heritage of many South Asian and Chinese patients. Further research about the interaction between English language proficiency (‘linguistic acculturation’) of ethnic minorities and ethnic differences in patient experience would be useful.28
However, socio-cultural aspects of ethnic identity other than linguistic competency may also be responsible. For South Asian patients, ethnic differences were consistent across different measures of patient experience (online appendix s1 and s2). For Chinese patients, however, reported differences were smaller for access questions and larger for all other questions (including doctor communication and overall satisfaction). These findings may reflect differences in care or in the understanding of the meaning of questions among patients of different ethnic minority groups, which may particularly occur for general as opposed to specific (report-like) questions ().20
We plan to conduct primary research on the understanding of different questions from the General Practice Patient Survey by patients of different ethnic groups.
In common with other studies, we found that older patients evaluate their experience more positively compared with younger patients.6 11
Like two other UK studies (measuring socioeconomic status either with individual measures,6
or practice area deprivation8
) we found that socioeconomic differences in patient experience of primary care were limited and inconsistent.6 8
These UK findings contrast with many US studies reporting that higher levels of patient education are associated with lower patient experience scores.7 11 19
A particular strength of our study is its UK setting, where there is universal access to healthcare, so our findings indicate that large ethnic group differences in patient experience may be present even within countries with universal healthcare coverage. Another strength of the study is its large sample size, enabling the precise measurement of the experience of patients belonging to relatively small ethnic groups; and of the variation in such differences across practices. For example, we were able to determine that the less positive experiences reported by South Asian patients held for Indian, Pakistani and Bangladeshi patients, and that Black patient subgroups (defined by national origin) reported similar experiences.
A limitation of our study is that although we provide some insight about potential causes of ethnic differences, we were not able to directly measure whether expectations of healthcare quality or survey responses tendencies varied among patients of different ethnic groups20
; nor whether the quality of care provided (particularly the standard of inter-personal care and doctor communication quality) was actually different.28
Another limitation is that the overall average response rate was 38%. Groves and Peytcheva, in recent reviews of the survey methodology literature, suggest that among probability sample surveys adhering to typical process standards of survey methodology, response rates are only weakly associated with non-response bias,29
a conclusion consistent with our previous analysis of non-response bias for the two questions associated with payments to practices.12
Our findings have clear policy implications (box 1
). First, they indicate that large differences in healthcare experiences may exist among patients belonging to different socio-demographic groups, even when arrangements for universal coverage of healthcare are in place. However, such differences are not inevitable because we found that minority ethnic group patients reported a range of experience scores in different primary care practices, sometimes comparable with, or even better than those reported by White patients. Providers could seek to mitigate potential ethnic inequalities by introducing measures such as access to translation or interpreting services for non-native speaker patients, and interventions to increase the cultural competency of healthcare professionals.
Box 1. Putting the findings into context
Previous studies have indicated that patient experience of either primary or hospital care varies among different socio-demographic groups,3–11 17 26 27
(see also online appendix s3). Most available evidence relates to studies of sub-national healthcare systems. There is evidence from various contexts that concentration of patients of different groups in healthcare provider organisations with lower than average performance is responsible for a proportion of socio-demographic differences. Variation in differences among organisations across a national healthcare system with universal coverage has not been previously described.
In England, a country with universal healthcare coverage, ethnic minority patients (particularly South Asians and Chinese), younger patients and those with poor self-rated health reported substantially more negative experiences of primary care than White patients, older patients and those in better health. Ethnic differences in patient experience were comparable in magnitude to the differences observed among patients in ‘poor’ and ‘excellent’ self-rated health. A substantial proportion of ethnic differences reflected concentration of ethnic minority patients in low-performing practices. Primary care practices showed substantial ethnic differences. In some practices ethnic minority patients evaluated their experience similarly or more positively compared with White patients, and such practices could be studied as models for quality improvement.
Second, a substantial proportion of the observed lower patient experience scores of South Asian and Chinese ethnic group patients in England reflects their concentration in practices with lower than average scores. Therefore, if the overall performance of low-performing practices were improved (as is the goal of a series of major UK government policy initiatives) this would also help improve the patient experiences of South Asian and Chinese patients and reduce ethnic inequalities. Previous UK research indicates that national primary care quality improvement schemes could help reduce variability and socioeconomic inequalities in technical processes of primary care,30
though whether such improvements can also be expected for non-technical dimensions of care quality such as patient experience is currently uncertain. Alternatively, if patients were able to change their practice (ie, moving from practices with low to high mean patient experience scores) this could in principle also reduce ethnic differences. Current policy initiatives of the UK government aim to support patients by giving them a wider choice of practice.14
However, the impact of such policies may be limited by the potential geographical clustering of low-performing practices; by patient preference for geographical proximity to their practice (particularly in rural areas); or other trade-offs between preferences for quality of patient experience and other aspects of care quality.
Third, the fact that within-practice ethnic differences varied markedly from practice to practice suggests that, at least in part, ethnic differences arise from differences in what practices do (‘worse care’ hypothesis, ). Practices that provide uniformly positive experiences to patients of all socio-demographic groups (including ethnic minorities and patients with poor self-rated health) could be studied as models for quality improvement in other practices.